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General NPI Number Information
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NPI Number | 1073987483
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Entity Type | Organization
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Legal Business Name | SOUTHERN DENTAL GROUP BALD KNOB, PLLC
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Dates
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Enumeration Date | 11/23/2015
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Last Update Date | 11/23/2015
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Provider Practice Location Address
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Address Line | 2802 HIGHWAY 367 N
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City | BALD KNOB
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State | AR
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Zip | 72010-3165
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Country | US
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Telephone | 870-243-4406
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 17151
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City | JONESBORO
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State | AR
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Zip | 72403-6720
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Country | US
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Telephone | 870-243-4406
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Fax |
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. WILLIAM REYNOLDS LITTLE
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Credential | D.D.S.
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Telephone | 870-243-4406
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 3930
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License Number State | AR
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